Ischaemic Heart Disease and Arrythmia

Question 1

How can stress increase your risk of CVD? (4)

Answer 1

Impacts:

1. diet
2. level of exercise
3. alcohol intake
4. smoking

Question 2

Name 4 examples of chronic stressors that can increase risk of CHD

Answer 2

1. Socioeconomic status
2. work stress
3. marital stress
4. caregiver strain

Question 3

What pathological mechanism leads to increased risk of CHD with stress?

Answer 3

Increased activation of HPA axis and sympathetic nervous system, which induces various pathophysiological responses that increase risk of CHD

• hypertension
• inflammation
• insulin resistance

Question 4

1. What type of response does repeated stress lead to?

2. What can also happen with repeated stress?

Answer 4

1. Anticipatory stress response

2. slower recovery following each stressor

Question 5

1. What is Primary Appraisal with respect to stress?

2. What is Secondary Appraisal with respect to stress?

Answer 5

1. appraisal of the life event as a threat/ whether it is a harm/benefit
2. Appraisal of personal coping abilities to cope with stress (e.g. resources available; coping strategies)

Question 6

Describe the dual process model of grief:

1. loss orientated tasks
2. restoration orientated tasks

Answer 6

1. grief work, breaking bonds, denial

2. doing new things, new relationships etc

Question 7

1. What is cardiac neurosis/Da Costa’s Syndrome?
2. What is it associated with?
3. How is it pharmacologically managed
4. How else is it managed?

Answer 7

1. Psychiatric disorder involving chest pain, SOB, rapid pulse, fatigue, palpitations with no underlying cardiac pathology
2. exhaustion and emotional strain
3. Antidepressants
4. psychological support/therapy
   modification of lifestyle factors
   regular visits to same team

Question 8

What are the 4 cardinal signs of cardiac disease?

Answer 8

1. chest pain
2. breathlessness
3. Palpitations
4. Syncope

Question 9

1. What are the three characteristics of typical / definite angina?
2. Where might angina radiate to?
3. Name 4 features of chest pain that make a diagnosis of stable angina unlikely

Answer 9

1. acute substernal chest pain
   provoked by exertion or emotional stress
   improves with rest or GTN spray
2. jaw or left arm
3. continuous/prolonged
   unrelated to activity
   brought on by breathing
   assocated with other symptoms such as dizziness, palptatations etc

Question 10

What is the character of pain associated with:

1. myocarditis
2. pericarditis
3. dissecting aortic aneurism

Answer 10

1. vague and mild pain, associated with systemic symptoms
2. sharp stabbing pain worse on inspiration and lying flat
3. substernal pain often described as sudden, excrutiating tearing that radiates to the back

Question 11

1. What is pulmonary oedema?
2. What is paroxysmal nocturnal dyspnoea
3. What cardiac pathology are these associated with?

Answer 11

1. oedema of the lungs. Characterised by orthopnea and pink frothy sputum
2. waking from sleep with coughing and wheeze, lasting for around 15-30 mins
3. Heart failure

Question 12

1. When does vasodepressor syncope usually occur?
2. What is it a response to?
3. What is carotid sinus hypertrophy?
4. What is it important to listen for?

Answer 12

1. after prolonged standing
2. response to stress
3. can induce syncope by rubbing neck (and compressing baroreceptors)
4. carotid bruit

Question 13

1. Name 3 cardiac causes of clubbing
2. What are osler’s nodes?
3. What are Janeway’s lesions?
4. What are these indicative of?
5. What are splinter haemorrhages indicative of?
6. What is arcus senilis?
7. What is xanthalma?

Answer 13

1. congenital cyanotic heart disease
   infective endocarditis
   Atrial myxoma
2. painful red raised lesions of the finger pulps
3. erythematous macular lesions on the hypothenar eminence
4. infective endocarditis
5. infective endocarditis
6. peripheral corneal opacity; can appear due to hyperlipidemia
7. fatty deposits around the eyelids. Sign of familial hypercholesterolaemia

Question 14

What events happen causing the JVP waveform:

1. A
2. X descent
3. C wave
4. V wave
5. Y descent

Answer 14

1. atrial systole
2. end of atrial contraction
3. tricuspid valve closure
4. venous return against closed tricuspid valve
5. opening of the tricuspid valve

Question 15

1. What event causes S1?
2. What event causes S2?
3. What is the cause of a third heart sound?
4. What us the cause of a fourth heart sound?

Answer 15

1. closure of mitral and tricuspid valves
2. closure of the aortic and pulmonary valves
3. beginning of diastole, after S2. low pitch. Indicative of LV FAIURE
4. before S1 at end of diastole. blood forced into stiff ventricle. failing LV

Question 16

1. What does a fatty streak consist of?
2. In which blood vessel layer does it develop?
3. What forms over the top of a fatty streak?
4. What happens to the core of an atheromatic lesion?
5. What happens when the structure (3) becomes thin and ruptures?

Answer 16

1. aggregates of foam cells (macrophages that have ingested LDLs)
2. tunica intima
3. fibrous cap
4. becomes necrotic
5. necrotic core is exposed - leads to thrombus formation and further vessel occlusion

Question 17

1. What is the presentation of angina in diabetics?

2. What two tests are used to confirm a diagnosis of angina?

Answer 17

1. worsening of breathlessness
2. stress echocardiogram - area of heart supplied by occluded vessel is less dynamic
3. myocardial perfusion scan

Question 18

What conditions are included in the term Acute Coronary Syndrome? (3)

Answer 18

1. UNSTABLE ANGINA
2. NON-ST ELEVATION MI - partial occlusion, therefore only small section of heart is damaged
3. ST ELEVATION MI - total occlusion of artery, causing extensive damage to a large area

Question 19

What do the following coronary vessels supply?

1. Left main stem
2. Left Anterior Descending
3. Right Coronary Artery
4. Which infarcts tend to have worse outcomes?

Answer 19

1. left side of heart
2. most of LV, RV, and IV septum
3. Right side of heart, including SA node and AV node
4. anterior - RCA, LAD

Question 20

Which ECG leads produce the following views of the heart?:

1. Inferior
2. Anterior
3. Lateral

Which arterial occlusions can be viewed with the following views?

4. Inferior
5. Anterior
6. Septal

Answer 20

1. II, III, aVF
2. V1-V6
3. V5, V6, aVL
4. RCA
5. LAD
6. LCx

Question 21

1. What ECG changes may be seen in NSTEMI? (2)

2. What is the prognosis if ECG changes are seen?

Answer 21

1. ST depression
   T wave changes/Inversion
2. poor

Question 22

1. What 4 pharmacological agents are used for NSTEMI treatment?
2. What is the treatment for STEMI? (2)

Answer 22

1. antiplatelets - ticagrelor or presurgel
   low molecular weight heparin
   statins
   anti-ischamic - beta blocker, nitrates
2. primary percutaneous coronary intervention
   thrombolysis

Question 23

Name 4 consequences of Coronary Occlusion/MI

Answer 23

1. Myocardial Rupture
2. Left Ventricular Dysfunction
3. left ventricular aneuriusm
4. Sudden Cardiac Death

Question 24

1. What is a marker for left ventricular dysfunction?

2. How can sudden cardiac death be prevented?

Answer 24

1. NTproBNP

2. implanted defibrilator

Question 25

On an ECG, how many squares make up a normal: 1. QRS complex? 2. PR interval 3. What is the QTc? 4. How can normal sinus rhythm be calculated?

Answer 25

1. <3 small squares 2. <5 small squares 3. QT interval divided by the square root of RR interval 4. divide 300 by the number of large squares in an R R interval

Question 26

BRADYCARDIA What does it mean if the QRS complexes are: 1. regular 2. irregular 3. What does it mean if there are irregular QRS complexes and absent P waves

Answer 26

1. sinus bradycardia 2. heart block 3. slow AF

Question 27

What is the ECG trace of: 1. first degree heart block 2. second degree heart block type I 3. second degree heart block type II 4. third degree heart block

Answer 27

1. Regular QRS complexes; Prolonged PR interval 2. PR interval gets longer until it skips a QRS 3. Regular QRS complexes but not always a P wave present before 4. Regular QRS complexes but wide and slow (indicating they originate from the ventricles); no P wave in front of each QRS

Question 28

1. What is bundle branch block 2. Do the R and L sides of the heart conduct synchronously or asynchronously? What is the ECG trace of: 3. Left BBB 4. Right BBB

Answer 28

1. conduction delay in the bundle branches 2. asynchronously 3. W shape in V1; M shape in V6 4. M shape in V1; W shape in V 6

Question 29

1. What is the treatment of sinus bradycardia? 2. What pharmacological treatments can be given for heart block? 3. What is the treatment of second or third degree heart block

Answer 29

1. investigate and remove cause 2. ATROPINE - muscarinic antagonist that stimulates the AV node 3. pacemaker

Question 30

TACHYCARDIA 1. What does it mean if QRS <3 small squares? 2. What does it mean if QRS >3 small squares 3. What does it mean if QRS complexes are irregular? 4. What pharmacological agent can be given to determine whether tachycardia is supra-ventricular or ventricular?

Answer 30

1. supraventricular tachycardia 2. ventricular tachycardia 3. Atrial fibrilation 4. Adenosine - blocks the AV node - will have no effect on ventricular tachycardia

Question 31

What is the mechanism of: 1. Atrial tachycardia? 2. Atrioventticular re-entrant tachycardia 3. AV nodal re-entrant tachycardia

Answer 31

1. drive of electrical activity comes from ectopic pacemaker in the atria rather than the SA node 2. commonly associated with Wolff Parkinson White Syndrome - an accessoty pathway between atria and ventricles creates re-entrant circuit 3. re-entrant circuit forms within or just next to AV node

Question 32

What is the ECG trace of: 1. atrial flutter? 2. Atrial Fibrilation 3. Ventricular Tachycardia 4. Ventricular Fibrilation

Answer 32

``` 1. one P wave for every large square saw tooth appearance 2. absent P waves; irregular QRS complexes 3. wide, regular, rapid QRS complexes 4. chaotic ```

Question 33

1. What is torsades de pointes? 2. Which class of anti-arrythmic drugs can cause TDP? 3. What two electrolyte balances can cause TDP?

Answer 33

1. polymorphic ventricular tachycardia 2. class 1 3. low potassium and magnesium

Question 34

How do you treat: 1. stable supraventricular tachycardia? 2. stable ventricular tachycardia? 3. Atrial fibrilation?

Answer 34

1. vagotonic manoeuvres, adenosine 2. amiodarone, cardioversion 3. rhythm control, ventricular rate control and anti-thrombotic medication

Question 35

Describe the following phases of the cardiac action potential: 1. Phase 4 2. Phase 0 3. Phase 1 4. Phase 2 5. Phase 3

Answer 35

1. resting Vm = -9omV 2. depolarisation. Opening of fast gated sodium channels 3. rapid inactivation of Nav brief opening and closing of potassium channels makes Vm slightly less positive 4. Plataeu caused by opening of slow voltage gated Ca channels 5. repolarisation - potassium channels

Question 36

1. What is the absolute refractory period? 2. What is the relative refractory period? 3. What is the clinical relevance of the relative refractory period?

Answer 36

1. during phases 0-2 and half of phase 3, where myocytes can't be excited again 2. last half of phase 3, where stimulation may result in contraction 3. relevance for DC cardioversion; stimulation during the RRP may result in R on T phenomenon, which may cause VF.

Question 37

1. What is the treatment of bradycardia? 2. What can be given if the cause of bradycardia is beta blocker or Ca channel blocker overdose? 3. What can be given if the cause of bradycardia is digoxin toxicity?

Answer 37

1. Atropine - muscarinic antagonist (blocks parasympathetic innervation which slows the heart rate) Also stimulates the AV node 2. glucagon 3. digoxin specific antibody fragments

Question 38

What is the site of action of the following classes of anti-arrythmic drugs: 1. class I 2. Class II 3. Class III 4. Class IV

Answer 38

1. sodium channel blockers - reduce rate of depolarisation 2. beta blockers - reduce background sympathetic tone and decrease SA node conduction 3. Potassium channel blockers - prolong repolarisation (refractory period) 4. Calcium Channel Blockers - prolong plateau

Question 39

Name Examples of: 1. Class I antiarrythmics 2. Class II antiarrythmics 3. Class III antiarrythmics 4. Class IV antiarrythmics

Answer 39

1. Lidocaine 2. Atenolol 3. Amiodarone, solatol 4. Verapamil, amlodipine